5-year Recurrence-free Survival For Patients Research Articles

Stratifying the outcome after neoadjuvant treatment using pathological response classification by the Japanese Breast Cancer Society.

Neoadjuvant chemotherapy (NAC) is one of the standard treatment for patients with operable and locally advanced breast cancer. Pathological response after NAC has been assessed according to the Japanese Breast Cancer Society (JBCS) classification in Japan. This classification that was first established in 1998 and revised in 2007 has been used in routine clinical practice in Japan. In the present study, we investigated whether the assessment of pathological response according to this classification could stratify the long-term outcome of patients with breast cancer. Patients with breast cancer who had received neoadjuvant chemotherapy between January 2003 and December 2005 in 6 hospitals participating in this study were identified. Patients whose response was judged to be Grade 2 was reassessed into Grades 2a and 2b according to the updated JBCS classification revised in 2007. Then, the association of pathological response and recurrence-free survival (RFS) was analyzed. 635 patients received NAC and 154 relapses (24 %) were observed during a median follow-up of 41.5 months (range 4.2-69.5 months). There was a statistically significant difference in RFS among each pathological response. 5-year RFS of patients with Grade 3 without residual ductal carcinoma in situ was 94 %. 5-year RFS were 88 % in Grade 3, 95 % in Grade 2b, 80 % in Grade 2a, 73 % in Grade 1b, 67 % in Grade 1a, 59 % in Grade 0, respectively. An outcome could be stratified by assessing tumor burden following NAC according to the JBCS classification.

The role of single instillation chemotherapy in patients who receive subsequent bacillus Calmette-Guérin: A retrospective single centre study, and systematic review of the literature.

This retrospective study was undertaken to evaluate the combined effect of immediate intravesical chemotherapy and subsequent bacillus Calmette-Guérin (BCG) therapy. The study population consisted of 207 intermediate- or high-risk patients with non-muscle invasive bladder cancer who underwent an induction course of BCG between 1993 and 2007. We introduced single immediate instillation of 50 mg epirubicin for all cases in 2004, and thus earlier cases could be considered as historical controls. The primary endpoint was recurrence-free survival (RFS). For cumulative analysis, we systematically reviewed studies indexed in databases. Including ours, the records of 856 patients from a total of 7 studies, including ours, were finally analyzed. In our cohort, the 5-year RFS in patients who received the combination therapy was 66.2%, compared to 55.2% in the BCG alone group (p = 0.149). Multivariate analysis on tumour recurrence showed that patients with the combination therapy had a hazard ratio (HR) of 0.74 (p = 0.189). A subsequent literature review revealed that RFS rates in the combination groups were higher than those in the corresponding BCG alone groups in 4/7 studies (p = 0.02-0.15), and lower in 1 study (p = 0.51). We identified 5 studies which examined a HR for combination therapy, and performed a cumulative analysis. Adding a single chemo-instillation prior to BCG resulted in a significant reduction in tumour recurrence (summary HR 0.69, p = 0.010). Our analysis suggested that the combination of single chemo-instillation with subsequent BCG therapy exhibited an additive effect against potential tumour recurrence.

MP44-11 PROGNOSTIC SIGNIFICANCE OF DEGREE OF RENAL VEIN INVOLVEMENT IN PATIENTS WITH PATHOLOGIC T3A RENAL CELL CARCINOMA

You have accessJournal of UrologyKidney Cancer: Evaluation and Staging II1 Apr 2015MP44-11 PROGNOSTIC SIGNIFICANCE OF DEGREE OF RENAL VEIN INVOLVEMENT IN PATIENTS WITH PATHOLOGIC T3A RENAL CELL CARCINOMA Myungsun Shim, Myungchan Park, Aram Kim, Mooyoung Sohn, Jaeyoon Jung, In Gab Jeong, Cheryn Song, Choung-Soo Kim, and Hanjong Ahn Myungsun ShimMyungsun Shim More articles by this author , Myungchan ParkMyungchan Park More articles by this author , Aram KimAram Kim More articles by this author , Mooyoung SohnMooyoung Sohn More articles by this author , Jaeyoon JungJaeyoon Jung More articles by this author , In Gab JeongIn Gab Jeong More articles by this author , Cheryn SongCheryn Song More articles by this author , Choung-Soo KimChoung-Soo Kim More articles by this author , and Hanjong AhnHanjong Ahn More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1553AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES We aimed to evaluate prognostic significance of degree of renal vein (RV) involvement in patients with T3a RCC. METHODS We retrospectively reviewed the data of 322 T3a RCC patients who underwent nephrectomy between 1997 and 2012 with a follow-up period of at least 1 year. Tumors with perinephric fat, sinus (fat) invasion and RV involvement were identified as T3a tumors, and degree of RV involvement were classified as RV thrombi only (TI) and RV wall invasion (WI). Recurrence-free survival (RFS) and cancer-specific survival (CSS) rates were assessed by Kaplan-Meier curves. Predictors of RFS and CSS were analyzed by Cox regression models. RESULTS One hundred eighteen (36.6%) patients with RV involvement showed significantly worse outcomes compared with 204 (63.4%) patients without RV involvement in terms of 5-year RFS (30.0% vs 54.9%, p < 0.001) and CSS (51.4% vs 75.4%, p < 0.001). Within the patients with RV involvements, 5-year RFS of patients with TI and WI was 49.8% and 16.4% (p < 0.001) whereas CSS was 68.5% and 47.4% (p = 0.001) respectively. Especially, tumors invading venous wall with margin involvement showed worst prognosis (RFS, 0.0%; CSS, 28.6%). Pathologic tumor size, Fuhrman grade (3, 4 vs 1, 2), sarcomatoid differentiation and WI was an independent predictor of recurrence (p < 0.001, 0.012, 0.026 and 0.006, respectively) and cancer death (p = 0.008, 0.026, 0.018, and 0.017, respectively) while TI was not (p = 0.575, 0.803, respectively). Tumors with TI showed comparable prognosis to those of perinephric or sinus invasion. CONCLUSIONS Tumors with RV involvement demonstrated different outcomes according to degree of involvement. The prognosis of tumors that invades venous wall in T3a RCC should be considered as those of tumors that involves vena cava. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e530 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Myungsun Shim More articles by this author Myungchan Park More articles by this author Aram Kim More articles by this author Mooyoung Sohn More articles by this author Jaeyoon Jung More articles by this author In Gab Jeong More articles by this author Cheryn Song More articles by this author Choung-Soo Kim More articles by this author Hanjong Ahn More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Prognostic relevance of biological subtype overrides that of TNM staging in breast cancer: discordance between stage and biology.

Recently, we faced difficult treatment decisions regarding appropriate adjuvant systemic treatment, especially for patients who show discordance between stage and tumor biology. The aim of this study was to compare the prognostic relevance of the TNM staging system with that of intrinsic subtype in breast cancer. We retrospectively identified women patients who received curative surgery for stage I-III breast cancer with available data on immunohistochemistry profiles including hormone receptor (HR) status, human epidermal growth factor receptor 2 (HER2) status, and Ki 67 staining at the Samsung Medical Center from January 2004 to September 2008. Primary outcomes were recurrence-free survival (RFS) and overall survival (OS). A total of 1145 patients were diagnosed with breast cancer and received curative surgery. Of these, 463 (40.4%) patients were stage I, and 682 (59.6%) were stage II or III. In addition, 701 (61.2%) patients were HR positive, 239 (20.9%) were HER2 positive, and 205 (20.9%) had triple-negative breast cancer. The 5-year RFS for the patients who were HR positive and HER2 negative with a low Ki 67 staining score (0-25%) was 99%. The 5-year RFS for patients who were HER2-positive or had triple-negative breast cancer were 89 and 83%, respectively (P value = <0.001). In multivariate analysis, advanced stage (II/III) and unfavorable biology (HER2 positive or triple negative) retained their statistical significance as predictors of decreased RFS and OS. Patients with advanced-stage disease (II or III) but favorable tumor biology (HR positive and HER2 negative and low Ki 67) had better clinical outcomes than those with stage I disease and unfavorable tumor biology in terms of RFS (99 versus 92%, P value = 0.011) and OS (99 versus 96%, P value = 0.03) at 5 years. The current results showed that intrinsic subtype has a greater prognostic impact in predicting clinical outcomes in subpopulations of patients with stage I-III breast cancer who show discordance between stage and biologic subtypes.

Prognostic relevance of postoperative platelet count in upper tract urothelial carcinoma after radical nephroureterectomy

Aim of the studyTo assess the impact of perioperative platelet count (PLT) kinetics on recurrence-free survival (RFS) after radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC). MethodsFrom three prospectively maintained databases of three tertiary care centres a total of 269 patients undergoing RNU without perioperative treatment between 1996 and 2011 were considered for this analysis. Pre- and postoperatively elevated PLT count was defined as >400×109/L. PLT levels were measured 1–3days preoperatively and 7–10days postoperatively. The median follow-up was 24months (Interquartile range (IQR): 10–52). A new weighted scoring model was developed to predict recurrence after RNU based on significant parameters of multivariable analysis. ResultsThe 5-year RFS in patients with preoperatively normal and elevated PLT count was 58.3% and 29.3%, respectively (p<0.001). The 5-year-RFS was 57.6% in patients with normal postoperative PLT count and 29.7% in those with elevated PLT levels (p<0.001). In multivariable analysis, pT-stage, lymphovascular invasion, ureteral margin status and postoperative thrombocytosis remained independent predictors for RFS. The 5-year RFS in patients with a score of 0 (low-risk), 1 (intermediate-risk) and 2–4 (high-risk) was 77.7%, 47.5% and 12.3%, respectively (p<0.001). Consideration of the variable postoperative thrombocytosis in the final model increased its predictive accuracy by 1.9% with a concordance index of 0.758 (p=0.015). ConclusionPLT kinetics is significantly associated with RFS after RNU for UTUC. We constructed a simple, PLT-based prognostic model for recurrence after RNU.

MP13-03 IMPACT OF SYNCHRONOUS BLADDER CANCER ON RECURRENCE-FREE SURVIVAL AFTER SURGICAL TREATMENT FOR PRIMARY URETHRAL CANCER: RESULTS FROM THE INTERNATIONAL COLLABORATION ON PRIMARY URETHRAL CARCINOMA (ICPUC)

MP13-03 IMPACT OF SYNCHRONOUS BLADDER CANCER ON RECURRENCE-FREE SURVIVAL AFTER SURGICAL TREATMENT FOR PRIMARY URETHRAL CANCER: RESULTS FROM THE INTERNATIONAL COLLABORATION ON PRIMARY URETHRAL CARCINOMA (ICPUC)

Presentation and surgical results of incidentally discovered nonfunctioning pituitary adenomas: evidence for a better outcome independently of other patients' characteristics

Few data are available on the surgical results in patients with incidentally discovered nonfunctioning pituitary adenoma (NFPA). We investigated the efficacy and safety of surgery in patients with incidentally discovered NFPA. Retrospective analysis of prospectively recorded outcomes. From 1990 to 2011, of 804 consecutive patients undergoing surgery for NFPA, 212 cases had an incidentally discovered tumor (26.4%). Among them, 117 patients were asymptomatic, while 95 had some visual and/or hormonal deficit. The main outcome of the study was to evaluate the frequency of radical resection as judged on the first postoperative neuroimaging study and detection of recurring disease during long-term follow-up. Postoperative residual tumor was detected in 8.9% of patients with asymptomatic incidentalomas as compared with 31.2% of patients with symptomatic incidentalomas (P<0.001) and 41.2% of patients in the control group (P<0.001). Multivariate analysis confirmed that having an asymptomatic incidentaloma was independently associated with a better outcome. The 5-year recurrence-free survival in patients with incidentaloma was 86.8% (95% CI 80.2-92.4%) as compared with 77.9% (95% CI 73.6-82.2%; P<0.01) in the control group. This difference was almost completely due to a lower frequency of relapse in asymptomatic patients. Multivariate analysis confirmed the independent lower risk of tumor recurrence in asymptomatic NFPA. Our study shows for the first time that surgically treated patients with asymptomatic NFPA have a better early and long-term outcome that is independent from all the other demographic, clinical, and morphologic characteristics of the patients.

Recurrence after operative management of intrahepatic cholangiocarcinoma

Data on recurrence after operation for intrahepatic cholangiocarcinoma (ICC) are limited. We sought to investigate rates and patterns of recurrence in patients after operative intervention for ICC. We identified 301 patients who underwent operation for ICC between 1990 and 2011 from an international, multi-institutional database. Clinicopathologic data, recurrence patterns, and recurrence-free survival (RFS) were analyzed. During the median follow up duration of 31 months (range 1-208), 53.5% developed a recurrence. Median RFS was 20.2 months and 5-year actuarial disease-free survival, 32.1%. The most common site for initial recurrence after operation of ICC was intrahepatic (n = 98; 60.9%), followed by simultaneous intra- and extrahepatic disease (n = 30; 18.6%); 33 (21.0%) patients developed extrahepatic recurrence only as the first site of recurrence. Macrovascular invasion (hazard ratio [HR], 2.08; 95% confidence interval [CI], 1.34-3.21; P < .001), nodal metastasis (HR, 1.55; 95% CI, 1.01-2.45; P = .04), unknown nodal status (HR, 1.57; 95% CI, 1.10-2.25; P = .04), and tumor size ≥ 5 cm (HR, 1.84; 95% CI, 1.28-2.65; P < .001) were independently associated with increased risk of recurrence. Patients were assigned a clinical score from 0 to 3 according to the presence of these risk factors. The 5-year RFS for patients with scores of 0, 1, 2, and 3 was 61.8%, 36.2%, 19.5%, and 9.6%, respectively. Recurrence after operative intervention for ICC was common. Disease recurred both at intra- and extrahepatic sites with roughly the same frequency. Factors such as lymph node metastasis, tumor size, and vascular invasion predict highest risk of recurrence.

Tumor islands in resected early-stage lung adenocarcinomas are associated with unique clinicopathologic and molecular characteristics and worse prognosis.

Tumor islands-large collections of tumor cells isolated within alveolar spaces-can be seen in lung adenocarcinomas. Recently we observed by 3-dimensional reconstruction that these structures were connected with each other and with the main tumor in different tissue planes, raising the possibility of tumor islands being a means of extension. However, the clinical and prognostic significance of tumor islands remains unknown. In this study, we compared clinicopathologic and molecular characteristics and prognosis of stages I to II lung adenocarcinomas with tumor islands (n=58) and those without (n=203). Lung adenocarcinomas with tumor islands were more likely to occur in smokers, exhibit higher nuclear grade and a solid or micropapillary pattern of growth, and harbor KRAS mutations. In contrast, lung adenocarcinomas without tumor islands were more likely to present as minimally invasive adenocarcinoma, show a lepidic pattern of growth, and harbor EGFR mutations. Although there was no difference in stage, the prognosis of lung adenocarcinomas with tumor islands was significantly worse than those without. The 5-year recurrence-free survival for patients with tumor islands and those without was 44.6% and 74.4%, respectively (log rank P=0.010). The survival difference remained significant (P <0.020) by multivariate analysis, and the presence of tumor islands was associated with almost 2-fold increase in the risk of recurrence. Even in the stage IA cohort, more than half of the patients with tumor islands experienced recurrence within 5 years. Thus, aggressive surveillance and/or further intervention may be indicated for patients whose tumors exhibit tumor islands.

FOXP1, an estrogen-inducible transcription factor, modulates cell proliferation in breast cancer cells and 5-year recurrence-free survival of patients with tamoxifen-treated breast cancer.

Breast cancer is primarily a hormone-dependent tumor that can be regulated by the status of steroid hormones, including estrogen and progesterone. Forkhead box P1 (FOXP1) is a member of the forkhead box transcription factor family and has been reported to be associated with various types of tumors. In the present study, we investigated the expression of FOXP1 in 133 human invasive breast cancers, obtained by core biopsy, by immunohistochemical analysis. Nuclear immunoreactivity of FOXP1 was detected in 89 cases (67%) and correlated positively with tumor grade and hormone receptor status, including estrogen receptor alpha (ERα) and progesterone receptor, and negatively with pathological tumor size. In ERα-positive MCF-7 breast cancer cells, we demonstrated that FOXP1 mRNA was upregulated by estrogen and increased ERα recruitment to ER binding sites identified by ChIP-on-chip analysis within the FOXP1 gene region. We also demonstrated that proliferation of MCF-7 cells was increased by exogenously transfected FOXP1 and decreased by FOXP1-specific siRNA. Furthermore, FOXP1 enhanced estrogen response element-driven transcription in MCF-7 cells. Finally, FOXP1 immunoreactivity was significantly elevated in relapse-free breast cancer patients treated with tamoxifen. These results suggest that FOXP1 plays an important role in proliferation of breast cancer cells by modulating estrogen signaling and that FOXP1 immunoreactivity could be associated with the estrogen dependency of clinical breast cancers, which may predict favorable prognosis in the patients treated with tamoxifen.

Apoptotic protein expression in favorable-histology Wilms tumor correlates with tumor recurrence

Outcome for patients with Wilms tumor (WT) with favorable histology is good. Deletions of chromosomes 1p and 16q impart a poorer outcome. Value of apoptotic protein expression is not clear. Expression of four immunohistochemically detectable apoptosis-regulating proteins (bcl-2, bcl-x, bax and p53) were analyzed in 30 specimens of WT and compared to recurrence and recurrence-free survival (RFS). The 30 patients included ranged from 4 to 72months in age (mean 31). The mean available follow-up was 35.3months (range 1-54). Six patients developed recurrence. The 5-year RFS for blastema-predominant tumors was 40% as compared to 91% for triphasic histology which was significant (p=0.048). The 5-year RFS in patients with bcl-2 negative tumors was 63% as compared to 100% for bcl-2 positive tumors, the difference being significant (p=0.019). The 5-year RFS in patients with p-53 positive tumors was 27% as compared to 91% for p-53 negative tumors; however, this difference in the RFS was not statistically significant (p=0.143). bax and bcl-x expression were not related to the RFS. Tumors that are bcl-2 negative have a relatively higher recurrence rate and a poorer RFS. They may benefit from a more intensive follow-up regime for early detection of recurrence.

Circulating Tumor M2 Pyruvate Kinase and Thymidine Kinase 1 Are Potential Predictors for Disease Recurrence in Renal Cell Carcinoma After Nephrectomy

Pyruvate kinase type M2 (TuM2-PK) and thymidine kinase 1 (TK1) are the key enzymes involved in tumor cells metabolism and proliferation. We explored the association of their preoperative circulating levels with disease recurrence in patients with renal cell carcinoma (RCC). We measured the plasma levels of TuM2-PK levels and serum TK1 activity preoperatively in patients with RCC, using a quantitative ELISA, and correlated the results with clinicopathological parameters. Significantly higher levels of TuM2-PK and TK1 were found in 116 patients with RCC compared with 20 healthy participants (P < .001 and P = .03), but not compared with 27 patients with benign kidney tumors (P = .13 and P = .72). There was a significant association between the level of TuM2-PK and of TK1 activity with T stage (P = .01 and P = .04). Of 2 markers only TuM2-PK was significantly associated with tumor grade (P = .001). The presence of extensive tumor necrosis (> 50%) was associated with high TuM2-PK (P = .001) and low TK1 (P = .03). The 5-year recurrence-free survival for patients with elevated TuM2-PK or TK1 was significantly lower compared with those for patients with normal marker levels (55% vs 94%, P < .001 and 21% vs 90%, P = .002). Multivariate Cox Proportional Hazard analysis demonstrated that TuM2-PK and TK1, adjusted for stage, grade and tumor necrosis were retained as independent predictors of disease recurrence (HR = 7.3, P = .04 and HR = 3.8, P = .03). The measurements of 2 circulating biomarkers, TuM2-PK and TK1, in RCC patients before nephrectomy can be useful for predicting recurrence and stratifying the patients into risk groups for possible adjuvant treatment.

Phase 1/2 study of preoperative docetaxel and mitoxantrone for high‐risk prostate cancer

: A study was conducted to determine the 5-year recurrence-free survival in patients with high-risk prostate cancer after neoadjuvant combination chemotherapy followed by surgery. Secondary endpoints included safety, pathologic effects of chemotherapy, and predictors of disease recurrence. : Fifty-seven patients were enrolled in a phase 1/2 study of weekly docetaxel 35 mg/m(2) and escalating mitoxantrone to 4 mg/m(2) before prostatectomy. Patients were treated with 16 weeks of chemotherapy administered weekly on a 3 of every 4 week schedule. A tissue microarray, constructed from the prostatectomy specimens, served to facilitate the exploratory evaluation of biomarkers. The primary endpoint was recurrence-free survival. Disease recurrence was defined as a confirmed serum prostate-specific antigen (PSA) >0.4 ng/mL. : Of the 57 patients, 54 received 4 cycles of docetaxel and mitoxantrone before radical prostatectomy. Grade 4 toxicities were limited to leukopenia, neutropenia, and hyperglycemia. Serum testosterone levels remained stable after chemotherapy. Negative surgical margins were attained in 67% of cases. Lymph node involvement was detected in 18.5% of cases. With a median follow-up of 63 months, 27 of 57 (47.4%) patients recurred. The Kaplan-Meier recurrence-free survival at 2 years was 65.5% (95% confidence interval [CI], 53.0%-78.0%) and was 49.8% at 5 years (95% CI, 35.5%-64.1%). Pretreatment serum PSA, lymph node involvement, and postchemotherapy tissue vascular endothelial growth factor expression were independent predictors of early recurrence. : Preoperative chemotherapy with docetaxel and mitoxantrone is feasible. Approximately half of the high-risk patients remain free of disease recurrence at 5 years, and clinical and molecular predictors of early recurrence were identified. Cancer 2010. (c) 2010 American Cancer Society.

Outcome After Radical Cystectomy With Limited or Extended Pelvic Lymph Node Dissection

We compared recurrence patterns and survival of patients with urothelial bladder cancer undergoing radical cystectomy who either had limited or extended pelvic lymph node dissection at 2 institutions between 1987 and 2000. Two consecutive series of patients treated with radical cystectomy and limited pelvic lymph node dissection (336; Cleveland Clinic) and extended pelvic lymph node dissection (322; University of Bern) were analyzed. All cases were staged N0M0 prior to radical cystectomy, and none were treated with neoadjuvant radiotherapy or chemotherapy. Patients with PTis/pT1 and pT4 disease were excluded from analysis. Pathological characteristics based on the 1997 TNM system and recurrence patterns were determined. The overall lymph node positive rate was 13% for patients with limited and 26% for those who had extended pelvic lymph node dissection. The 5-year recurrence-free survival of patients with lymph node positive disease was 7% for limited and 35% for extended pelvic lymph node dissection. The 5-year recurrence-free survival for pT2pN0 cases was 67% for limited and 77% for extended pelvic lymph node dissection, and the respective percentages for pT3pN0 cases were 23% and 57% (p <0.0001). The 5-year recurrence-free survival for pT2pN0-2 cases was 63% for limited and 71% for extended pelvic lymph node dissection, and for pT3pN0-2 cases the respective figures were 19% and 49% (p <0.0001). Incidence of local and systemic failure correlated closely with pathological stage for both series. Our data suggest that limited pelvic lymph node dissection is associated with suboptimal staging, poorer outcome for patients with node positive and node negative disease, and a higher rate of local progression. Extended pelvic lymph node dissection allows for more accurate staging and improved survival of patients with nonorgan confined and lymph node positive disease.

TREATMENT FOR DUCTAL CARCINOMA IN SITU IN AN ASIAN POPULATION: OUTCOME AND PROGNOSTIC FACTORS

Breast cancer is the most common cancer among Singapore women and ductal carcinoma in situ (DCIS) is believed to be the precursor of most invasive breast cancers. The incidence of DCIS has increased dramatically with mammographic screening, but its treatment remains controversial. Further, results of treatment for DCIS in Asians, and in particular Singapore women, are lacking. We review our institution's results treating a predominantly Chinese population with DCIS of the breast before the introduction of mammographic screening and aim to determine treatment outcomes and identify prognostic factors for disease recurrence. Between January 1994 and December 2000, 170 consecutive patients with DCIS were treated at our institution. One hundred and three (60.5%) were managed with breast conservation (17 with local wide excision alone and 86 with adjuvant irradiation following wide excision) whereas 67 (39.4%) underwent mastectomy. Of those who underwent wide local excision, 56 (54.3%) underwent re-excision for margin clearance. Overall, the axilla was surgically staged in 47 (27.6%) and no nodal involvement was found in all cases. Pathological specimens were reviewed by one of the authors. Median follow up was 86 months (range 4-151 months). Sixty-two patients (36%) were asymptomatic at presentation whereas most (64%) presented with clinical symptoms; out of these more than half (54%) presented with a palpable lump. The median size of tumours was 13 mm (range 1.5-90 mm). Patients who underwent breast conservation surgery had oncologically more favourable lesions - with a significantly higher incidence of smaller and non-palpable lesions and lesions of lower nuclear grade. However, there was also a significantly higher incidence of local recurrence in this group. At the end of follow up, there were 12 patients (7.1%) who developed local recurrence and 8 patients (4.7%) developed contralateral disease. The crude incidence of all breast events (including both local failure and contralateral events) at 5 years was 5.6%. Median time to the development of any breast event (local recurrence or contralateral disease) was 60 months (range 12-120 months). The cumulative 5-year recurrence-free survival for patients who underwent breast conservation surgery was 94%. Factors influencing local recurrence rate were close or involved margins (<or=1 mm) and lack of adjuvant radiotherapy. There were no cancer-specific deaths during the period of follow up. Our results indicate that rates of cancer-specific survival were similar after mastectomy and breast conserving surgery. However, a close or involved margin (<or=1mm) and lack of adjuvant radiotherapy were associated with local recurrence, with margin status being the independent predictor for local recurrence. Our results reinforce that optimizing local therapy is crucial to improve local control rates in women treated with DCIS in our population.

Low recurrence rate of hepatocellular carcinoma after liver transplantation: better patient selection or lower immunosuppression?

Liver transplantation is currently offered to a limited number of patients with hepatocellular carcinoma (HCC) because of strict criteria introduced in the past to avoid recurrence. Immunosuppression represents a risk factor for tumor growth; the schedules of the immunosuppressant drugs have been modified through the years, aiming to reduce their dosage to the effective minimum. A series of 106 consecutive patients with HCC who underwent transplantation over a 15-year period at a single institution was retrospectively reviewed to ascertain whether tumor recurrence was influenced by the Milano criteria presently adopted in patient selection and whether the dosage of immunosuppressant agents administered was associated with tumor recurrence. Fifteen patients who died postoperatively and 9 with a follow-up of less than 1 year were excluded; presence of the Milano criteria, tumor-node-metastasis staging, and the cumulative dosage of the single immunosuppressants given at different intervals in the first postoperative year were analyzed in the remaining 82 patients. The influence of these variables on overall and recurrence-free survival was assessed statistically. The Milano criteria did not influence recurrence-free survival, which was instead associated with the cumulative dosage of cyclosporine administered in the first postoperative year (93% 5-year recurrence-free survival for patients given low dosage vs. 76% for those given high dosage; P=0.01); T3 and T4 tumors did worse than T1 and T2 tumors. Current limits to transplantation for HCC might be reassessed in view of modified patient management; immunosuppression should be minimized in these patients.